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Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global priorities

Sunday, August 30, 2009

.The death of Senator Edward Kennedy this week was sad and sobering. Even this longest-lived of the Kennedy brothers, the only one to not die by a bullet in war or from an assassin’s gun, the one who served 47 years in the US Senate, still experienced tragedy at the end of his life. When someone dies, there is a natural tendency, in eulogies, to talk only about their positive attributes. In Senator Kennedy’s case, these are not only well-deserved, but important. I am not talking about his personal life, or things that happened long ago; I am talking about his public life as a leader.

“FESSLER: Political consultant Bob Shrum recalls how he almost got his head bitten off during Kennedy's reelection campaign in 1994 against Republican Mitt Romney. Shrum had given this political advice: Don't oppose Romney's plan to stop welfare for women who have children out of wedlock.Mr. BOB SHRUM (Political Consultant): And he said I'm not going to do that. I'm not going to get reelected by taking food out of the mouths of poor kids. I don't need the job that much. They need the food. He was genuinely angry.FESSLER: Shrum says it was part of Kennedy's deep philosophical belief.Mr. SHRUM: I think Ted Kennedy always had a very strong feeling that government existed for people who didn't have power and didn't have privilege and didn't have influence, that it somehow or other was a balancing mechanism to achieve a measure of social justice and opportunity and equality.”

I didn’t know this story, before, and I can’t say that I always thought that the Senator was doing everything I thought he could to advance healthcare for all, but I can say that this pretty much seems like the right definition of the purpose of government. And this should define what our government, representing our people, should be doing to reform health care.

Of course, not everyone believes that this is the purpose of government, but I do. I am not talking about the national defense, or the building of federal highways but in its core approach to domestic spending. Small business loans should help small businesses, people who are starting up or trying to get through hard times to achieve the American dream, not big companies. Farm support, to the extent we have it, should protect and help the family farmer, not giant agribusiness companies. We need to protect our nation’s natural resources and public lands so that they will be there for future generations, not destroy them to create more enormous wealth for multi-national corporations. Huge multinational corporations (and make no mistake, all of these large ventures from farming to mining to manufacturing to finance are controlled by large multinational corporations) and the extremely wealthy people who control them are doing just fine, thank you. If some of them are doing a little less fine than they were a year ago, that is fine also, and no one should shed a tear even if they are forced to move into public housing (hah!) – see my entry on the “Super Rich”, August 27.

But there are lots of people who do need help. They include the children that Senator Kennedy knew needed food, and who also need education. Nicholas Kristof, writing in the New York Times on August 19, 2009 (http://www.nytimes.com/2009/08/20/opinion/20kristof.html?scp=16&sq=&st=nyt), notes that while the Oakland, CA schools spend $8,000 per year to educate each of its students, the state of California spends $216,000 per year for each inmate in its juvenile justice system. If these children had a little more spent on their eduation, perhaps they won’t be in the same situation as another man described by Kristof, who, having had two minor convictions at 19, landed in jail for life for stealing a $2.50 pair of socks, under California’s 3 strikes law! Prison for life for stealing $2.50! While the bankers and financiers who were true bandits get government bailouts! Um, wrong use of taxpayer money.

And we need healthcare for all, which Senator Kennedy long fought for. By the end of his life, with the greatest possibility of achieving this goal on the horizon, he was unfortunately willing to give up on the plan he knew would work best, single payer, but would never give up on the need for a public plan, because he would not give up on the idea that everyone needed to be covered, and there are only 3 ways to do this: single payer, a public plan (more costly, as I have discussed previously), and a system using not-for-profit private insurance companies that are highly regulated, forcing them to cover everyone and not gouge them with his premiums (which has less chance of happening than single payer!) We need to do this he, and I, belive, because that should be the role of government: to be a balance, to help those who need the help to meet have the basic requirements for a good life, and to spend not a penny padding the accounts of the least needy in a manner that is often believed to be characteristic only of backward, corrupt, third-world dictatorships.

Not everyone agrees that government should be involved in health care reform. “The federal government has absolutely no business in any way, shape or form addressing health care,” an attendee at a town hall held by Sen Claire McCaskill of MO was quoted as saying by the Kansas City Star on August 24 (http://www.kansascity.com/news/politics/story/1403874.html). “Not pro, not con. Zero. Zip.” The article did not contain more information explaining this position, but I’m certain it was coherent as well as cogent. I'm sure that this person would be happy to eliminate the benefits offered by taxpayers not only for Medicare and Medicaid, but also the Veteran’s Administration, and the military and all federal employees. Not to mention the benefits supplied by all the state and local governments for their employees. Or the tax revenue foregone (thus a cost) by the federal government for making employer health contributions (perhaps including the employer of the person making this comment) tax-deductible. While the Center for Medicare and Medicaid Services (CMS) estimates the federal contribution to be 45% of healthcare spending, this doesn’t include the benefits for federal employees, state and local employees, or the tax breaks. When they are, appropriately, included, it brings the taxpayer-supported contribution to healthcare to nearly 60%.[1] In absolute per capita dollars, the US taxpayer spends more than the TOTAL per capita healthcare spending of every country save Switzerland, while having 47 million uninsured! We pay for national health care, but do not get it.

Go out, all of you covered by government funds, and get your own private health insurance!

Perhaps the commenter at the McCaskill event meant that he believed that he and everyone else should pay for their health insurance themselves in after-tax dollars. Or maybe he, or others who might be tempted to agree with him, are victims of the “Craig T. Nelson Fallacy”. This fallacy, of which “keep the government’s hands off my Medicare!” is an example, is named for the actor who, after an extensive anti-government rant on Fox’s Glenn Beck show, declared “I've been on food stamps and welfare. Anybody help me out? No. No.” (May 28, 2009, http://www.foxnews.com/story/0,2933,522939,00.html).

While many may dismiss Mr. Nelson as an ignorant blowhard who doesn’t know what he is talking about (which he is and is true), the real issue is that so many other people are missing the key point: how much they, personally, benefit from the government, and how helping them, and others in need, is a completely appropriate thing for the government to do. The “government” after all should be representing all of us, and helping us when we have need, not stuffing the pockets of the privileged (who, in turn, stuff the pockets of our representatives).

On MSNBC’s “The Morning Grind” on August 25, 2009, Rep. Anthony Weiner (D., NY), a single-payer advocate, left host Joe Scarborough “speechless” (many links all over the web; here is one:http://click.icptrack.com/icp/relay.php?r=4798182&msgid=254377&act=0LH3&c=196437&admin=0&destination=http%3A%2F%2Fwww.pnhp.org%2Fmultimedia%2Fanthony_weiner_leaves_scarborogh_speechless.php) by his simple logic that said, essentially (paraphrase) “why should we pay insurance companies such a big cut of our health care dollar? When did an insurance company ever operate on someone or make a diagnosis?” Scarborough could not believe that the Congressman was urging that insurance companies be eliminated, but all he could basically say was “I believe in private enterprise, and you want the government to run healthcare!”, unable, of course, to respond to the content. Weiner noted that if private insurance companies could really do a better, more cost-effective job, they wouldn't be concerned about competing with a public option.

Apparently Joe Scarborough, and many others, have an ideological belief different from that of Senator Kennedy. They believe that government should support rich corporations rather than existing “…for people who didn't have power and didn't have privilege and didn't have influence,” and being “a balancing mechanism to achieve a measure of social justice and opportunity and equality.” I believe that it was largely in agreement with this purpose that so many people became activated in the campaign of Barack Obama and elected him President. The President would be doing us all a great favor if he could ignore the advice of the (pre-reconstructed) Bob Shrums who advise him to abandon that belief, and provide the leadership that he can to create a health reform that is truly reform, that will truly cover all the people of the United States, and that willing truly be a fitting tribute to Senator Kennedy.

I do not mean to say that all super-rich folks are bad people. Some worked hard, got lucky, had a product or an idea that no one else had, and were able to turn it into great wealth. Others inherited it – ok, they did nothing to earn the wealth, but maybe they are spending it in very socially-conscious ways, supporting the movement for the environment and limiting climate change, working for peace, helping feed the hungry and house the homeless in this country and abroad.

But the “30-year run” is largely a story of greed gone wild. It is a story of the society that was among the most middle-class in world history, with poor people and rich people and some very rich people, to a society with lots of poor people, a declining role for the middle and upper middle class, and a relatively large (though still tiny) group of super-rich. It is a story of policies begun in the Reagan administration and carried through the subsequent administrations, both Republican and Democratic, of limiting restrictions and regulations that helped to keep business relatively honest. It encouraged lying, cheating and racketeering by making so much of it legal that some folks weren’t even sure where the line was. (Of course, some purposely stepped over the line.) It is a story that came to a head this last year with the near-collapse of the economy of the US and the world. It is good to hear that many of these people are losing their money, it is sad to hear that so many are not; they are getting money from the government (you and me) and spending it on bonuses for themselves. They have no humility.

I am looking forward to the creation of a memorial for these 30 years. Perhaps it can be prominently displayed in the broom closet of one of the surplus FEMA trailers that I have been advocating selling to these people after all their money is forfeit.

So what does this have to do with medicine? It has to do with social justice and with health reform. The current backtracking by the administration on the “public option” is shameful and inappropriate. The concept that co-ops could somehow cover everyone is flawed. Perhaps if they were true consumer-owned cooperatives, like most of the original groups (later called HMOs), such as Group Health of Seattle (one of the few remaining), Ross-Loos of Los Angeles, HIP of NY. But most of the consumer-cooperative HMOs, created by believers in cooperatives who felt that by cutting out the middleman – the insurance company – they could get more care for the same money or the same care for less money – were taken over, beginning in the 80’s, by – Insurance Companies! One of the threats that they faced, which made them susceptible to takeover, was increased costs without a willingness (or ability) to have increased premiums as their membership aged. It is strangely parallel to the history of the Israeli kibbutz – young idealists could do a lot when they were young and healthy, but as they aged, without replacement young workers, they found it difficult to survive. So a “co-op” owned by the insurance company would be the HMO that we have grown to know and hate over the last 20+ years, the one that makes money by denying us coverage. A true co-op movement would be neat for those who are in it, but would do nothing to help cover the uninsured. Whoops, let that cat out of the bag!

The whole concept misses the key, #1, worthless-if-it-isn’t-included, issue of health reform: It must cover everyone. Not like the economic “growth” we had when all those super-rich were created which left so many people out, and left out even more when we look at health coverage. Every year corporations, including the many controlled by these super-rich, cut benefits, cut coverage, increased co-pays, and even dropped health insurance altogether for dependents and sometimes for the workers themselves. The unions, whose job it should have been to protect the interests of their members, the workers, were greatly weakened by the same government policies that protected the super-rich and encouraged the financial-speculators-who-produce-nothing-but-steal-from-us-all crowd. And those unions who still had good health insurance had no interest in fighting for the rest of workers; they were too busy trying to hold on to their own. Like, for example, the UAW. Whoops, there went GM and “Cadillac” health benefits!

No, the only thing that will allow everyone to be covered is a public plan. As I have said often, the best public plan is one that covers everyone in one plan. But no “reform” absent a public plan will cover everyone. The objections to the “government” takeover of health care are, with the exceptions of those voiced by right-wing ideologues who are in the pay of the big “super-rich” corporations, misguided. Let’s look at some public plans. Medicare. No one who has it wants to lose it. At a recent town hall meeting, US Senator Claire McCaskill (D-MO) asked the audience how many had Medicare. About a third of those in attendance raised their hands. Then she asked (and I paraphrase) “how many of you want to give up your government-controlled public health insurance?” All hands went down.

Arguably, the only program as popular as Medicare is Social Security itself. A government plan. Like Medicare, it is government run, but the expenditure of funds is up to the individual. Remember the Republican plan, the Bush plan, to “privatize” Social Security? To invest the funds “in the market”? To take advantage of the huge growth of the stock market? I bet a bunch of current and soon-to-be seniors are breathing a big sigh of relief that that didn’t happen, but Republicans and other conservatives (what are they conserving? Not your retirement!) are still touting the same ideas! And the objections that they have brought up to health reform, such as the “death panels”, are completely spurious. But they are tenacious ideas, because of the big lie (as I addressed on August 11, “Should it be a crime to be poor – or instead to criminalize poverty”) and because of the psychology of stories and narrative, as addressed by George Lakoff in the Huffington Post (http://www.huffingtonpost.com/george-lakoff/the-policyspeak-disaster_b_264043.html#postComment)

In the Kansas City Star on August 20, 2009, Providence Journal columnist Froma Harrop wrote that “Health insurers have their own death panels” (http://www.kansascity.com/273/story/1395629.html). In it she describes the pain that she and her husband went through with their insurance company, United Health Care (the one that gave CEO William McGuire a more than $1 Billion bonus in 2006 http://money.cnn.com/magazines/fortune/fortune_archive/2006/07/10/8380799/index.htm; yes, that United Health Care) trying to get treatment for his liver cancer. I do not have access to his medical records and cannot comment on the appropriateness of the care or not, but she makes it absolutely clear that there ARE “death panels” now, and they are operated by private insurance companies.

The basis of the opposition to a public option, to single-payer, is opposition to what will be good for Americans in pursuit of corporate profit and political gain. In his op-ed in the Times August 24, 2009, “All the President’s Zombies”, (http://www.nytimes.com/2009/08/24/opinion/24krugman.html?ref=opinion), Paul Krugman makes this point very clearly; in echoes of Reaganism opponents of health reform keep trumpeting “government” when it is entirely clear, if you think about it, that it is only government programs that are likely to work, to cover everyone. He notes that DEMOCRATIC Sen. Ben Nelson of Colorado has “…warned ominously that if the option were available, Americans would choose it over private insurance — which he treats as a self-evidently bad thing, rather than as what should happen if the government plan was, in fact, better than what private insurers offer.” What is this, the Twilight Zone?

Commenting on the Democrats’ need to have A BILL, Cokie Roberts, on NPR Morning Edition August 24, 2009, that the Republicans will not vote for any health bill because they don’t want the Democrats to be able to take credit for it, as they have for years for Social Security and Medicare. She is probably correct. She also said that they have to have a bill that will not pass narrowly. I disagree. If a good bill, that will cover everyone with access to quality health, leave free choice of providers, eliminating prejudice against pre-existing conditions, and limits profit passes, the results will be wonderful and folks will love it more than they love Social Security and Medicare. Remember in TR Reid’s “Sick Around the World” (http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/), the Swiss plan barely passed with just over 50% of people supporting it in the early ‘90s, but now no one would give it up.

This is what the opponents of health reform fear; real change. We need to keep up the pressure to get it..

Sunday, August 23, 2009

Extensive research done by the Physicians for a National Health Program (PNHP), particularly by Steffie Woolhandler and David Himmelstein, have identified at least $400 BILLION in annual “waste” from our current system of health insurance (and, of course, lack of insurance for tens of millions of Americans). Drs. Woolhandler and Himmelstein are major advocates of a single-payer system, as am I (OK, I’m not so major!) and I have used much of their research in supporting single payer and in pointing out the limitations of a “public option”. Himmelstein, in his testimony to Congress (http://www.pnhp.org/news/2009/april/testimony_of_david_u.php) and in more detail on his PNHP blog (http://www.pnhp.org/campaign/materials/Refuting%20the%20Public%20Option.pdf) notes that a public option “…foregoes at least 84% of the administrative savings available through single payer. The public plan option would do nothing to streamline the administrative tasks (and costs) of hospitals, physicians offices, and nursing homes. They would still contend with multiple payers, and hence still need the complex cost tracking and billing apparatus that drives administrative costs. These unnecessary provider administrative costs account for the vast majority of bureaucratic waste. Hence, even if 95% of Americans who are currently privately insured were to join a public plan (and it had overhead costs at current Medicare levels), the savings on insurance overhead would amount to only 16% of the roughly $400 billion annually achievable through single payer.”

More than that, only a part of that 16% is actual insurance company profit, as noted in a letter to the New York Times (June 21, 2009) by Dr. Woolhandler: “Moreover, the savings on overhead from a public plan option are far smaller than you suggest. While it might cut insurers’ profits (which is why they hate it), that’s only 3 percent of the roughly $400 billion squandered on health bureaucracy annually.” (http://pnhp.org/blog/2009/06/25/paul-starr-and-steffie-woolhandler-on-the-public-option/).

Let’s think about that. We waste $400 billion a year in administrative overhead so that the insurance companies can make 3% of that, or about $10-15 billion. That is a lot of money, but it is also a high waste:profit ratio. We could just pay the insurance companies their $15 billion a year, maybe for a limited time (5-10 years, perhaps decreasing 10% per year, so they could get into some other business, perhaps cleaning up the environment or rebuilding infrastructure or teaching underserved inner-city children), and tell them to disappear, leave the debate, get out; then we do single-payer and save the other $385 billion.

Sounds like a good deal to me. And not so bad for the insurance companies, since they won’t have to work or bribe Congressmen! Sure, it is lacking in morality, but so was the bank bailout, and this is a lot cheaper. And it would get us a plan a lot better than any of those being tossed around by the administration and congressional committees.

Wednesday, August 19, 2009

.The Sunday New York Times, August 16, 2009, has a plethora of health-reform-related articles and opinion pieces, including an op-ed by President Obama himself (ok, signed by himself), which articulately makes the case for health reform, (“Why we need health care reform”, http://www.nytimes.com/2009/08/16/opinion/16obama.html). It includes a re-statement of his most important, and correct, point: “…what’s truly scary — truly risky — is the prospect of doing nothing.” This point is driven home by the lead editorial, “Lining up for help”, http://www.nytimes.com/2009/08/16/opinion/16sun1.html?ref=opinion , which itself is a commentary on the article from August 13, 2009, “Thousands line up for promise of free health care”, http://www.nytimes.com/2009/08/13/health/13clinic.html?ref=opinion. It describes the efforts of Remote Area Medical, “…which was formed to deliver care to Indians living in remote areas of the Amazon basin…” to deliver care to thousands of people at the Forum in Inglewood in Los Angeles. Not to Indians in the Amazon, not to refugees swarming in from abroad, but to Americans living in one of our great cities.

And Los Angeles, of course, is not alone, not by any means. Barbara Shelly writes in my local Kansas City Star (http://www.kansascity.com/277/story/1381919.html), about the story about thousands of people waiting to be seen in a traveling clinic in Wise, Virginia. She talks about the Southwest Boulevard Family Health Care clinic here in Kansas City, KS, where the medical director, my friend and colleague “Dr. Sharon Lee telephones friendly specialists and pleads with them to treat her uninsured patients with potentially life-threatening conditions.” To not recognize that such situations are not only daily occurrences all over the country, but that the number of people being affected by them grows daily, that President Obama’s assertion that the worst outcome would be to keep our current non-system , is irresponsible, wrong, and when done knowingly for political gain, evil. I addressed this in a recent blog entry, “Health Care Shoutdowns: Liars and Demagogues” (August 11, 2009), and the inflammatory lies continue even as the facts show them to be such.

“In the coming weeks, the cynics and the naysayers will continue to exploit fear and concerns for political gain,” the President writes, but they already are. Sarah Lyall of the Times reports from London (“Health Care in Britain: Expat Goes for a Checkup”, Sarah Lyall,http://www.nytimes.com/2009/08/16/weekinreview/16lyall.html?scp=1&sq=ex-pat&st=cseon the efforts of Investor’s Business Daily to disparage the health reform movement by comparing it to the British National Health Service, and stating that famed physicist Stephen Hawking, who suffers from amyotrophic lateral sclerosis (ALS, “Lou Gehrig’s Disease”) would not be able to get care if he lived in the UK. Of course, the problem is that Dr. Hawking does live in the UK, and has issued a statement saying that the NHS has kept him alive! (You can look at the link provided by Ms. Lyall, http://www.ibdeditorials.com/IBDArticles.aspx?id=333933006516877, but you won’t find IBD’s assertion there as they have pulled it from their article.)

One of the most irritating lies to me is that of the “death panels” that are called for in the administration and congressional health reform bills. Despite the fact that no such panel was ever called for in the bill, a point explicitly made by senior Republican Senator Charles Grassley when he noted that the end-of-life discussions provision had been dropped by the negotiators because of the misinterpretation of it, the liars and demagogues continue to press the point, led by former vice-presidential candidate and now-former Alaska governor, Sarah Palin: “Palin stands by ‘death panel’ claim”, (Matthew Daly, Associated Press, http://hosted.ap.org/dynamic/stories/U/US_HEALTH_CARE_END_OF_LIFE?SITE=CACRU&SECTION=HOME&TEMPLATE=DEFAULT ). Why I am particularly irritated about this is that it misrepresents a really important health care issue, one that we all need to think about: end-of-life care. It also misrepresents how decisions on limiting access to unproven treatments would be made. I have previously addressed the latter at some length (May 12, 2009, July 5, 2009), and probably will again, but today want to talk about the former.

The legislation under consideration (specifically HR 3200) said that the plan would pay for voluntary consultation with a physician about end-of-life care. We should all be thinking about end-of-life care. If and when we are diagnosed with a terminal disease, or are in extremis at the end of our lives, what do we want done? Treatments that will cure us and have us back to playing tennis? Most of us would say “You betcha!”, but this is not what we are talking about. We are talking about interventions that are done to maintain life, in its literal sense, and are sometimes successful (for a while; no one lives forever) ranging from the seemingly benign administration of nutrition in an atypical way (fluid through a vein, or liquid through a tube in the nose into the stomach or directly into the stomach), to maintaining breathing on a ventilator when there is no hope of ever being able to come off of it, to having electroshocks and chest compressions applied when your heart stops. Contrary to the portrayal on television shows, very few such cardiac resuscitations are done on relatively healthy, relatively young people who go on to survive to live normal lives. The vast, vast majority are done on terminally ill people, most do not survive the intervention, very few survive in a meaningful way – to hospital discharge, and hardly any return to their previous state of pre-hospital function.

Nonetheless, it may be that we choose to have such interventions at the end of our lives. While many of us would choose not to, might choose palliative care (the kind of care given by hospice) where we get everything we can possibly get to keep us comfortable and pain-free but not vain attempts at treatment, many of us might not. We might choose a “Living Will” that delineates what treatments we want and what treatments we don’t want, or we might not, asking for all treatments. But we should think about it, discuss it with our families and the others whose opinions we care about, including our doctors and other health care providers. We are much better off making those kinds of decisions when we are sentient, and able, than when we are unable to speak or are disoriented or in a coma.

And all of us should have a “Durable Power of Attorney for Health Care” (DPOA-HC), even those of us who are young and healthy, because, unfortunately, accidents happen. The DPOA-HC designates a specific person to make healthcare decisions for us when we are unable to do so for ourselves. This is a particularly wise idea for two reasons. One is that, while the law in most states designates an order of relations to make decisions (beginning with the legal spouse and continuing to adult children and then to adult parents) this can be a problem. The spouse may not, him or herself, be able or willing to make decisions. The children may disagree, and there is no law that says, for example, that the oldest has precedence, or that there is a vote. So it is best to designate one person, although we all hope that all of those we care for will agree. Perhaps the person you want to make the decision is a friend, a pastor, or an unmarried life partner.

The second reason is that it requires you to think about what you would want to happen in a situation where you cannot make your own decisions and to share these thoughts and discuss them with your designee (DPOA) and with others who will be involved. The DPOA is supposed to make decisions based on their understanding of what you would want, even if it is different from what they would want, and the way they understand this is for you to discuss it with them. It is also important to note that the DPOA cannot make decisions for you when you are able to make them for yourself, that it (and the Living Will, or any other “advance directives”) can be revoked by you at any time, and that it only covers health care decisions (not, for example, financial decisions).

All hospitals currently are required to ask patients when admitted if they have advance directives. This makes sense; if you’ve made these decisions, and you’re being admitted to a hospital where you hope good things will happen but they might not, you want them to know about them. Sarah Palin, as governor of Alaska, “signed a proclamation making April 16, 2008, Healthcare Decision Day with the goal to have health care professionals and others participate in a statewide effort to provide clear and consistent information about advance directives”. Most insurance companies pay for consultations with physicians about end-of-life care. Although Medicare does not, most primary care physicians do it anyway. This is altogether a good thing.

The current effort to portray advance directives as something they are not, as something bad, as euthanasia, is not only a scurrilous tactic to oppose health reform legislation, it is a terrible, terrible attack on good health care, on something we should all want to do..

Sunday, August 16, 2009

.Barbara Ehrenreich, in an Op-Ed piece in the NY Times on August 8, 2009, http://www.nytimes.com/2009/08/09/opinion/09ehrenreich.html?pagewanted=1&_r=2&ref=opinion, writes about the restrictive and repressive laws being passed – and enforced – against those who are the least fortunate in a country with a growing number of unfortunates. In “Is it now a crime to be poor?” she begins with the litany of penalties placed upon those who are homeless, including men like Al Szekely, a wheelchair-bound (from a bullet taken in Vietnam) veteran who lives in a homeless shelter. He was arrested –in the shelter – in a police sweep looking for outstanding warrants (don’t they have something better to do? Like arrest bankers or their congressional enablers?)

“It turned out that Mr. Szekely, who is an ordained minister and does not drink, do drugs or curse in front of ladies, did indeed have a warrant — for not appearing in court to face a charge of ‘criminal trespassing’ (for sleeping on a sidewalk in a Washington suburb). So he was dragged out of the shelter and put in jail. ‘Can you imagine?’ asked Eric Sheptock, the homeless advocate (himself a shelter resident) who introduced me to Mr. Szekely. ‘They arrested a homeless man in a shelter for being homeless.’”

Ehrenreich’s story continues, documenting the fact that arrests, for major or minor crimes – create a vicious circle. Employment is hard enough to come by these days, and if you have a criminal record it is nearly impossible. And “For the not-yet-homeless, there are two main paths to criminalization — one involving debt, and the other skin color. Anyone of any color or pre-recession financial status can fall into debt,” and the ways in which people of color are particularly victimized is both appalling and unsurprising. One of the ways in which this occurs is being ticketed – at rates of $250 to $500 – for truancy.

“According to the Los Angeles Bus Riders Union, an advocacy group, 12,000 students were ticketed for truancy in 2008. Why does the Bus Riders Union care? Because it estimates that 80 percent of the “truants,” especially those who are black or Latino, are merely late for school, thanks to the way that over-filled buses whiz by them without stopping. I met people in Los Angeles who told me they keep their children home if there’s the slightest chance of their being late. It’s an ingenious anti-truancy policy that discourages parents from sending their youngsters to school.”

I don’t mean to quote the entire Op-Ed here. Read it. But it pains me to think that there are so many people who are very close to the edge of such poverty, losing their jobs, close to it, who are involved in the anti-health-reform, anti-Obama, movement. One thing that they are not, almost entirely, is minority; they are almost all white. And they feel like victims. They feel – obviously inflamed by purely evil and corrupt parasites on talk radio and TV – that it is the “government” that is responsible for their situation, precariously close to the edge. They see the bailout of the bankers as an example of the government looking out for the wealthy and powerful – and I agree with them. But somehow, bizarrely, they can see the health reform process as again something being done by the government against them. They are wrong. They are acting against their own interests.

There have been times when the government has acted strongly against the interests of most of the American people – the Bush administration almost used that as a playbook: “What is good for the rich and screws regular people? And maybe kills their children overseas? Let’s do that!” The Obama administration is not at all without blame or complicity in this. By bringing in a bunch of Clinton administration veterans (read: “hacks”) to his administration, particularly in the area of treasury and finance, the Obama administration is accurately seen as a friend of the rich and powerful. Well, that is not a change. But they are trying to do something for all of us, to do health reform.

To make sure that all of us are covered, all of the time, whether we are working or we are not, whether we keep the same job or not, whether our employer is big and generous or small and barely surviving, whether we have a pre-existing condition or not or develop a new one, whether we are young or old. I am not a fan of the Obama / Congressional plan to include the evil empire of for-profit insurance companies in the solution, or the vain effort to try to get bipartisan support from a Republican party that is only capable of attack, and of nothing constructive. However, we need even more than the administration and Congressional Democrats are proposing. If people think (often correctly) that the government does not respond to its needs, that the people that they elect to serve and represent them are in the pockets of the big corporations, why in any possible way would they ever be able to imagine that it could be better if those corporations, responsible to no one but their shareholders, are directly in charge?

It is really scary, because it is so reminiscent of the rise of fascism. White working class people being manipulated, using the big lie[1] and racism, to act against their interests by the forces of corporate wealth.

I wrote to my senators, both Republican, both anti-health reform, and both mouthing anti-government slogans, that THEY are the government, and at least they are supposed to listen to me. Not to necessarily do what I want, but at least to listen to me and to the rest of their constituents. Private insurers have no such obligation.

I don’t think, however, that this is mainly about health insurance or health reform. It is a vicious, violent, reactionary, and racist attack by folks who feel threatened. Yes, as Barbara Ehrenreich indicates, those at the lowest rungs of the totem pole – the homeless, the really poor, and racial minorities are the first and most serious victims. But all of us are close to being victims and it is never helped by joining in attacks on the weakest. Attack the strongest. They can take it. Don’t be fooled.

[1] “All this was inspired by the principle - which is quite true in itself - that in the big lie there is always a certain force of credibility; because the broad masses of a nation are always more easily corrupted in the deeper strata of their emotional nature than consciously or voluntarily; and thus in the primitive simplicity of their minds they more readily fall victims to the big lie than the small lie, since they themselves often tell small lies in little matters but would be ashamed to resort to large-scale falsehoods. It would never come into their heads to fabricate colossal untruths, and they would not believe that others could have the impudence to distort the truth so infamously. Even though the facts which prove this to be so may be brought clearly to their minds, they will still doubt and waver and will continue to think that there may be some other explanation. For the grossly impudent lie always leaves traces behind it, even after it has been nailed down, a fact which is known to all expert liars in this world and to all who conspire together in the art of lying. These people know only too well how to use falsehood for the basest purposes. ...” , A. Hitler, Mein Kampf

According to these articles, many of the demonstrations are organized by Freedom Works, Tea Party Patriots, Sean Hannity and other well-funded right-wing groups. While freedom of speech is a good thing, preventing others from speaking, and preventing the events from occurring, is more suggestive of Brown Shirts than Americans. The conservative radio commentators, such as Hannity, O’Reilly, and Limbaugh, the right wing think tanks and activist groups, and the reactionary billionaire individuals and corporations that fund them, are bankrupt when it comes to health reform ideas, but are clear what they do not want. Coverage for all. A public option. A single payer system. Anything that will limit the profits of the insurance and pharmaceutical industries. But how do they get regular people out to yell and scream?

Well, some of them are ideologues themselves. Some of them have drunk the Kool-Aid of “no government” (except when it benefits me), or no socialism. There are always, in every country, multiple groups arrayed across the political spectrum. But the other way to get these folks out is to lie to them, to make them believe that health reform will take away their health care, limit access to their doctor, take away their current government benefits (“Keep the government’s hands off my Medicare!” is a nonsense chant heard all too often, and not nonsense to the chanter.) Misinformation is everywhere. A member of my family received an email containing the following nonsense: “…you will see that after 65 all Health Care will be limited and the people (SEC. to be specificied) will make our health care choices for us. Also the community service people will be in on the act to deny and/or approve (this is ACORN) OBAMA and his crew are denying what this plan is and they keep saying you get to choose, however, if you persist in reading you see that in 2013 all other plans are frozen out and only the public plan remains. Then the government wants access to your bank account so that after you are dead they(the government) can and will seize assets.”What? Are these paranoid nuts, or just liars?

More disturbing yet are the threats of violence, so far only involving fistfights. However, as reported by Rachel Weiner in the Huffington Post,http://www.huffingtonpost.com/2009/08/10/gabrielle-giffords-town-h_n_255656.html, “…one visitor dropped a gun at the meet n' greet held in a Douglas Safeway,” by Congresswoman Gabrielle Giffords (D., AZ); and these opponents were not only unhappy with the Congresswoman, but with the fact that trade unionists were present to support her. “One of the callers to the Service Employees International Union said, "I suggest you tell your people to calm down, act like American citizens, and stop trying to repress people's First Amendment rights... That, or you all are gonna come up against the Second Amendment."

OK. So I’m upset. Like a lot of pointy-headed intellectuals, I would rather argue the issues than shoot them out in the middle of the street like a hero in one of my beloved Marty Robbins songs (although Rep. Gifford might end up needing the services of the Arizona “Ranger with a big iron on his hip” http://www.cowboylyrics.com/lyrics/robbins-marty/big-iron-11880.html[1]). I do believe that supporters of health reform need to start turning out in massive numbers. But people who want to read more about this, including incisive commentary, have a lot to choose from. In addition to the sources cited above, there is an excellent piece from Robin Wells in the Huffington Post August 8, 2008, recommended by Paul Krugman, http://www.huffingtonpost.com/robin-wells/what-obama-needs-to-learn_b_254714.html, who notes that “Our uniquely noxious blend of racism, right wing politics, and moneyed interests exploiting racial fears and economic insecurity have hollowed out the core of moderation in American politics. In an unbroken line from Goldwater to Limbaugh and Palin, the Republican party has committed itself to scorched-earth tactics that have shredded the economic, political, and moral fabric of this country.”

What I can do is to address some of the concerns that people, such as my relative who sent me the anonymous email quoted above, may have after this right wing onslaught. The ones making these assertions, from Palin to Limbaugh to Hannity to O’Reilly to Mitch McConnell to John Boehner to Freedom Works are evil liars, but regular folks hearing these lies may legitimately be worried. OK, here goes:

No, the plans being put forward by the Democrats, President and Congress alike, are not going to euthanize your grandmother. They are not going to leave you naked, without health insurance. They are not going to cost you a lot more – in fact they are likely to cost you less, unless you are very wealthy. (Note: this descriptor, “very wealthy”, generally applies to the folks mentioned above and the owners of the big insurance companies and their lobbyists, but not to the folks actually showing up and yelling.)

These plans are not what I have been advocating for, a single-payer system where one payer would cover everyone, and save lots of money at the outside by elimination of not only insurance company profits but the massive inefficient billing and collecting infrastructure (see previous blog entries), but it is to the extent that they would come a little closer that is (to put it mildly) agitating the right.

No one will lose their Medicare. Indeed, much of the “public option” being discussed would be expanding Medicare, the most popular, and one of the most successful, government programs ever implemented, to more people. HR 676, the single-payer bill sponsored by Rep. John Conyers and cosponsored by nearly 100 house members, is in fact called the “Improved and Expanded Medicare for All” bill. HR 3200, the current house bill, is not single-payer but does expand Medicare. The costs will be higher than I would like, not because of any “government involvement” but specifically because of the retention of private health insurance, which will necessitate maintaining the huge and costly billing and collecting infrastructure. However, currently direct government funds account for nearly 40% of our health care spending (Medicare, Medicaid, insurance for government employees and retirees at all levels) and when the taxes not paid on employer-sponsored insurance are added in, it is almost 60%. That 60% of OUR healthcare spending, which leaves 47 million people uninsured and tens of millions of more poorly insured, is more than that spent, per capita, to cover everyone in any other industrialized country. Yes, multimillionaires might spend about $10,000 more per year under HR 3200. What is wrong with that? Regular people would not.

And no one is going to euthanize your grandmother. In fact, your grandmother, your mother, you, and your children will get better care. This is a “red herring”, a complete distortion of a discussion about efforts to control costs by not doing procedures that do not benefit people but still have the potential to harm them. This makes perfect sense, and is the way it should be, and is the way I want it to be, and is almost certainly the way everyone would want it to be for themselves and their families, but is not the way that it is now. The reimbursement system that we currently have rewards doing procedures, even procedures that are not proven to benefit anyone, that will definitely not benefit the patient affected, may do them harm, and often are expressly against a patient’s wishes (e.g., your grandmother who has expressed her desire to not have any interventions except those that increase her comfort). I have discussed this at length in various columns, including Feb 13, 2009, Jun 22, 2009 and especially “Clinical Guidelines and Technology Assessment”, May 12, 2009 http://medicinesocialjustice.blogspot.com/2009/05/clinical-guidelines-and-technology.html.)

The people who are stirring up the pot are liars and demagogues, looking out, at bottom, for the financial interest of the billionaires and insurance companies that fund them. Regular people should not believe them. We are better than that. We need to support a health reform program that covers everyone. And reject these scare tactics. And be vocal about it. And make sure that we don't allow Brown Shirts to set the tone of the debate.

[1] As best as I can find, copyright Elvis Presley Music, Inc., Unichappell Music Inc.

* I had an idea for a bumper sticker that was made for these people: "We don't need to provide health coverage to everyone. If you think it's wrong, we can leave YOU out!". Of course, the problem would be that they would turn it down when healthy and then coming asking for it when they got sick and needed it. We would have to make them sign waivers that they would never ask for it. Maybe their billionaire friends in the health insurance industry would take care of them..

Thursday, August 6, 2009

Recently, some of us in the medical profession have seen proposals from medical societies for letters that physicians can send to their patients, asking them to weigh in (with the opinion of the physician, or at least of the medical society, on health reform proposals. I suspect that many of the rest of us, as patients will receive them. The idea that physicians can multiply their level of influence on the policy debate is an interesting and not uncontroversial one; however here I will focus primarily on the content that those letters might take. Any position or letter taken by any large group, such as a medical society, will obviously have members who disagree in part or in whole with its content, but the fact that the medical society is weighing in may be quite influential.

The most important issue is the health of the American people, a very important component of which is access to health care. This means financial access without unreasonable barriers, geographic access, access to a primary care medical home, and access to proven, evidence-based diagnostic and treatment methods. It is also critically important that the cost of "health care" be controlled; I put it in quotes because a large part of that cost is in administrative costs. These costs, which are "waste" in the sense that they do not deliver health care to anyone, include, and are driven by, the enormous profits health insurance companies make, but are far more than that. They are in the huge billing and collecting infrastructures that the insurance companies (to try to not pay) and all providers (to try to get paid) have to have in place. Zero percent of this is from public programs, but the growth in administrators is astonishing (see slide).The issue is not, should not be, and absolutely cannot be seen to be, protecting the self-interest and incomes of doctors. This is not to say that doctors should not be reimbursed "fairly" for their services; certainly they have to be able to pay their staff and make a living. (Although note, above, that a lot of staff and physician time is spent on trying to get reimbursed!) In addition to any moral or ethical issues -- and it would be nice if physicians, who we ask the American people to trust with their most important assets, their lives and health -- would act, especially as an organized group, morally and ethically, there is the fact that physicians already make more money than most people. It may not always seem so if we live in the richest parts of town and thus compare ourselves to the richest people, but even the poorest paid primary care physicians are in the top few % of income, and many are in the 99+++%. Whether you think you deserve it or not, the typical employed, not to mention unemployed, American is not going to cry for you, and it is amazing that we would even think of asking them to.

Another huge cost driver is the growth of expensive technical procedures. Many of these are important diagnostic and therapeutic advances, and when evidence shows that they are beneficial they should be used, although the cost has to come down. The American people -- forget the government -- need to know that zero percent of any recommendation for a diagnostic or treatment intervention is motivated, even subconsciously, by the potential income it may bring to physicians. We must welcome, embrace, cheer -- and definitely be part of -- efforts to identify which strategies are evidence based, and for what populations, and what the cost benefit ratio is. (As to what ratio is acceptable, that is a different question, but one must be joined. It is NOT ok to say a huge cost to benefit ratio is ok for one person -- me or mine -- and not for another person.)

The basis of every effective health system is primary care, a primary care medical home. People need a doctor who knows them, who can help them work, if needed, with multiple specialists, help them interpret the jargon, help them know when two consultants who seem to the patient to be disagreeing really are not, and how to figure it out when they are. They need a doctor who knows them and their family, and what their health was like before they "fell from the sky" into the hospital, so that s/he can know when they are better. They need a primary care medical home because it is mainly primary care doctors who will be able to practice in rural areas, where 20% of the American people live and 9% of physicians practice -- and decreasing rapidly. Medical students are not entering primary care, and not going to rural areas; some of this may be lifestyle but much of it is financial. Organized medicine needs to take this issue on as its own, demanding policies that encourage a move toward a 50% primary care workforce. Even if it means some decrease in income for some specialists.

One of the letters I have seen uses anti-government scare tactics, which are indefensible. If there are members who do not believe that everyone should have access to the highest quality medical care, we are on different pages; that is a different discussion. Fear mongering of "government bureaucrats" coming between you and your doctor is just that; first of all, there are no such proposals. Secondly, the government bureaucrats could have nothing on the insurance bureaucrats. Let us not lose sight of the fact that the government -- including our congressmen and senators -- is supposed to be responsive to us. I know it may often seem as they are only responding to the biggest contributors (often including organized medicine), but for-profit insurance companies are not even supposed to care about our opinions; they are only obligated to their shareholders. A public option is necessary to ensure that all people are covered. If the insurance companies are confident that they are offering a better product, they should not be afraid of the public option competition. Indeed, it seems they are not so confident, but rather, contrary to the idea that the public sector will have "unfair" advantages, believe that they need the special privileges, "unfair advantages", that would come from hobbling the public sector. And, of course, a public option only saves a small percent of the cost of "non-medicine"; even if half of Americans were in it, we would all need to maintain our billing and collecting infrastructures for the rest.

Scare tactics that alarm our patients are inappropriate, undignified, and inappropriate. The medical profession has done well financially not because they studied hard (there are starving artists and musicians everywhere who study and practice hard) but because people trust them with their lives and health. To take any position other than that which is certain to have the greatest health benefit to all people -- lowest to highest income -- is a violation of that trust and is dishonorable. We are, we have to be, better than that..

Sunday, August 2, 2009

One thing a blog might do is to provide connections between seemingly disconnected news stories. I have tried to do that, as well as focus primarily on medicine and health issues, but also with an emphasis on the social justice implications (or at least that is my attempt). I will make that effort here.

On July 31, 2009, the New York Times has a lead article titled “Big banks paid billions in bonuses amid Wall St. Crisis” by Louise Story and Eric Dash (http://www.nytimes.com/2009/07/31/business/31pay.html?_r=1&hp). I have often made clear my feelings about those big bankers and financiers (that they should have all their money taken away and either be put in prison or in surplus FEMA trailers), but apparently the bankers do not share that opinion. The information for this story came from NY Attorney General Andrew Cuomo, and reports that “At Goldman Sachs, for example, bonuses of more than $1 million went to 953 traders and bankers, and Morgan Stanley awarded seven-figure bonuses to 428 employees. Even at weaker banks like Citigroup and Bank of America, million-dollar awards were distributed to hundreds of workers…. ‘If the bank lost money, where do you get the money to pay the bonus?’ said Mr. Cuomo." Good question; apparently the answer is either directly (from our deposits or loan payments), or indirectly (from TAFP funds), from you and me. “Some compensation experts questioned whether the bonuses should have been paid at all while the banks were receiving government aid.” You can add some non-compensation experts, like me, to that group.

On the health reform front, we are treated to news reports that President Obama’s popularity has slid to 53% with only 42% approving and 47% opposing their understanding of the President and Congress’ health plans (NPR July 28, 2009, and widely reported). I have been following the health reform debate pretty closely and I am not sure I understand what the President’s health reform plan is; even the ones that are proposed variously in the House and Senate keep changing, and are hard to tell even with a scorecard, such as that offered by the Kaiser Family Foundation website, http://www.kff.org/healthreform/upload/healthreform_sbs_full.pdf.Thus, there is a possibility that most of the Americans surveyed for this report also may not have a clear understanding. One of the reasons, of course, is the reporting in the media, which is always interested in conflict, as it sells better, and in the case, at least, of much of TV news – the source of most Americans’ information – frequently biased. One source of bias, even among less egregious offenders than Fox, is the constant parade of Republicans, a group whose contribution to the health debate has been limited to attacks and scare tactics.

The Republicans, of course, have no plan; it is a lot easier to shoot arrows at the Democratic proposal – any proposal – than themselves offer an actual plan that might be criticized. And, of course, it would be torn to shreds, since the only values that the Republicans share on health care is making sure that the wealthiest are protected in their wealth, that insurance and pharmaceutical companies make out like bandits, and that there be no government sponsored health plan, which effectively means not only would the currently uninsured be left out, but the currently underinsured and scared would be at even more risk.

The President has said the right things: Everyone must be covered. Costs must be controlled. There is no “null” option, the alternative is to continue things as they are and see massive growth in health care costs combined with more and more uninsured and underinsured people getting less and less health care that they need resulting in worsening health status for Americans. But the health plans being proposed by the Congress with the support of the White House are second rate (that is to say, they will not cover everyone and save money the way that a single player plan would). However, the big mistake is that the Congress has not supported the President’s play. Committed to repeating the mistakes of the Clinton health plan, they insist on compromises to try – absolutely without hope of success – to get bipartisan support. This is a mistake, as the Republicans have no credibility and are worthy of no respect or attention; this is, after all, the party of Alabama Senator Jeff Sessions, who voted against the confirmation of Sonia Sotomayor in the Judiciary Committee the same day because she has a judicial philosophy that is not consistent with the American ideal of Blind Justice. I suppose Sessions – whose own Supreme Court nomination faltered on the fact that he was tied to the Ku Klux Klan – has managed to pull the sheet over his own eyes.

Unfortunately, too many of the Democrats, as well as Republicans, are in the pockets of the lobbyists of wealthy billionaires and the huge companies, especially insurers and pharmaceutical companies but also large hospitals and hospital chains who stand to lose a great deal of money if we enact real health reform. After all, if there is “waste” in this system – and I think most informed people believe that there is – it is going into someone’s pocket. I call “waste” all those billions – hundreds of billions – of dollars spent on “health care” that is not spent on health care at all but insurance company profits and bloated administrative structures that are designed (on the insurance company side) to not pay, and (on the provider side) to try to get the insurance companies to pay. And the enormous mark-ups for certain drugs, such as cancer chemotherapy drugs. If we save all this money, certain companies won’t make it, and they are lobbying like heck to keep their piece of this huge, bloated, tasteless pie.

To call these “special interests” is, on the face of it, accurate, but deceptive because the term is without meaning. It has been developed and put forward precisely to hide the influence of wealthiest and most powerful corporations by conflating them with much smaller and weaker groups as “special interests”. Let us be clear: the influence of the Health Insurance Association of American or PhARMA is not the same as that of, say, those seeking rights for the transgendered. Or even of labor unions. These groups are powerful in our lives outside government all the time – hey, that is the problem, that the health insurance companies deny us coverage if we have pre-existing conditions, won’t insure us if we don’t work for a big company and don’t have the money to pay, makes us pay huge deductible and coinsurances, and still won’t pay the bills all too often. The one area of society that should be responsive to the needs of the people and not big corporations is our elected government, but the fact is that those companies have bought Congress too. After all, they have to run again and that requires a lot of money and it is a proven fact that wealthy individuals and corporations contribute a lot more money than poor and middle-class people. (What is it with those poor folks? Why don’t they contribute more to their congressmen?)

Which, of course, brings us back to the beginning of this piece. The problem facing health reform is the same problem facing reform of the financial and banking system. Money talks. Even after the gigantic disaster perpetrated by the banks and financial houses, the one that took down YOUR retirement, as well as, coincidentally, the entire US and world economy, they still have way more power than you do, and Congress is still feeding their interests. My last blog post addressed the “Tragedy of Meaning”, and how we like to explain suicide by people (like Adolph Merckle) as their reacting to bad events rather than because they suffer from depression. The best argument for that is in the first paragraph of this piece – of all those financial leaders who brought this ruin on all of us who are not committing hara-kiri but are demanding, expecting, and getting huge payoffs. The position being put forward that some of them are not the same individuals who were in charge before is nonsense; they have the same values, beliefs, and arrogance.

What can regular people do? We can be clear that we need a health reform plan that 1) covers everyone, every single one of us, 2) covers our needed services based on evidence, 3) doesn’t pretend that choice of insurance companies is the same as choice of doctors or hospitals. And that makes for every one of us to have access to all of the proven preventive and treatment modalities for the diseases we have or might get. And to write that email or make that phone call to our congressman daily if we have to. Start, for example, with urging them to vote for the Weiner Amendment in the House, which will come to the floor in September, that calls on the House to replace the current, flawed, patchwork HR 3200 health bill with HR 676, the Improved and Enhanced Medicare for All Bill, which will put us all in the same program (Medicare, the most popular government program in history) and at the same time revise payment structure to encourage what is GOOD for us rather than what is PROFITABLE for providers.

If the President and the Congress would just take the lead in not only saying, but proposing a plan, that would cover everyone and pay for it using the dollars currently wasted on both insurance company profit and the huge administrative infrastructure necessary to run that system; to say and propose a plan that says “we want health and health care for the American people and do not care a whit for the insurance industry”, the American people would be behind it.